,i #aaith ,,congress #b;d ,session ,h4 ,r4 #igdc ,,in ,,the ,,house ,,of ,,representatives ,july #af1 #bjbf,mrs4 ,harshbarger 7for herself1 ,mr4 ,carter of ,georgia1 ,mr4 ,mc,guire1 ,mr4 ,kennedy of ,utah1 ,mr4 ,carter of ,texas1 ,mr4 ,fuller1 ,mr4 ,van ,epps1 ,mrs4 ,biggs of ,south ,carolina1 ,mr4 ,babin1 ,mrs4 ,miller of ,illinois1 ,mr4 ,stutzman1 ,mr4 ,hamadeh of ,arizona1 and ,mr4 ,ciscomani7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,education and ,workforce1 and ,ways and ,means1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend title ,,xxvii of the ,public ,health ,service ,act1 the ,employee ,retirement ,income ,security ,act of #aigd1 and the ,internal ,revenue ,code of #aihf to require group health plans and health insurance issuers offering group or individual health insurance coverage that provide benefits for sex-rejecting procedures to provide benefits for items and services to address the harms caused by sex-rejecting procedures and to restore healthy human form and functioning1 to the greatest extent practicable4 #a4 ,short title ,this ,act may be cited as the ,treatment and ,restoration ,uniformity and ,transparency in ,health ,coverage ,act of #bjbf or the ,,truth in ,coverage ,act of #bjbf4 #b4 ,requiring group health plans and health insurance issuers offering group or individual health insurance coverage that provide benefits for sex-rejecting procedures to provide benefits for items and services to address the harms of such procedures 7a7 ,,phsa ,part ,d of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa et seq47 is amended by adding at the end the following new section3 #bgii;,a-#ab4 ,required coverage of items and services to address the harms of sex-rejecting procedures 7a7 ,in general ,a group health plan and a health insurance issuer offering group or individual health insurance coverage shall1 in the case such plan or coverage provides benefits with respect to any sex-rejecting procedure1 also provide benefits for items and services furnished to an individual who has received any such procedure to address the harms of such procedure 7including restorative care71 regardless of whether-- 7#a7 such individual received benefits with respect to the sex-rejecting procedure under the individual's plan or coverage2 or 7#b7 such plan or issuer provides benefits under the individual's plan or coverage for the sex-rejecting procedure4 7b7 ,application of financial requirements and treatment limitations ,a group health plan and a health insurance issuer offering group or individual health insurance coverage shall ensure that1 with respect to items and services for which benefits to address the harms of sex-rejecting procedures are required to be provided under such plan or coverage under subsection 7a7-- 7#a7 the financial requirements applicable to such items and services are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan or coverage and there are no separate cost-sharing requirements that are applicable only with respect to such items and services2 and 7#b7 the treatment limitations applicable to such items and services are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan or coverage and there are no separate treatment limitations that are applicable only with respect to such items and services4 7c7 ,definitions ,in this section3 7#a7 ,female ,referring to a natural person1 the term female means an individual characterized by a reproductive system naturally organized to produce 7at maturity1 absent disruption or congenital anomaly7 large gametes 7ova74 7#b7 ,financial requirement2 predominant2 treatment limitation ,the terms financial requirement1 predominant1 and treatment limitation have the meaning given such terms in clauses 7i7 through 7iii71 respectively1 of section #bgbf7;a77#c77;,b71 except that the term financial requirement shall include aggregate lifetime limits and annual limits4 7#c7 ,male ,referring to a natural person1 the term male means an individual characterized by a reproductive system naturally organized to produce 7at maturity1 absent disruption or congenital anomaly7 small gametes 7sperm74 7#d7 ,restorative care ,the term restorative care means items and services furnished to an individual who has received any sex-rejecting procedure at any point during the individual's lifetime to address1 mitigate1 monitor1 treat1 or reverse the harms1 complications1 and adverse effects of such procedure1 including interventions intended to restore1 to the greatest extent practicable1 healthy human form and functioning4 ,such care includes items and services furnished to address-- 7,a7 impaired reproductive capacity1 diminished ovarian reserve1 impaired spermatogenesis1 or other reproductive-system injury2 7,b7 endocrine dysfunction1 hormonal imbalance1 hypogonadism1 dependence on exogenous hormones1 or other disruption of healthy endocrine function2 7,c7 impaired sexual function1 including loss of sexual sensation1 anorgasmia1 erectile dysfunction1 genital pain1 vaginal stenosis1 diminished libido1 or other sexual dysfunction2 7,d7 urinary dysfunction1 including urinary incontinence1 urinary retention1 urethral complications1 recurrent urinary tract infections1 or other genitourinary injury2 7,e7 resultant vocal cord damage1 permanent voice changes1 vocal dysfunction1 or impaired speech2 7,f7 female hirsutism1 male-pattern baldness1 breast atrophy1 breast development1 or other secondary-sex-characteristic changes caused by cross-sex hormones2 7,g7 osteoporosis1 osteopenia1 impaired bone development1 fractures1 reduced bone density1 or other skeletal disorders associated with puberty suppression or cross-sex hormone use2 7,h7 cardiovascular disease1 thromboembolic disease1 hypertension1 stroke1 myocardial infarction1 metabolic syndrome1 diabetes1 or other cardiovascular or metabolic complications associated with such procedures2 7,i7 surgical complications1 including infection1 fistula formation1 stenosis1 tissue necrosis1 chronic pain1 nerve damage1 graft failure1 implant complications1 wound complications1 or the need for revision surgery2 7,j7 loss1 removal1 alteration1 or impairment of healthy reproductive organs1 breasts1 genital structures1 or other healthy tissues2 7,k7 reconstructive1 regenerative1 prosthetic1 plastic1 or other surgical interventions intended to restore healthy anatomy1 appearance1 or physiological function2 7,l7 rehabilitation services1 including speech therapy1 physical therapy1 occupational therapy1 pelvic floor therapy1 sexual health counseling1 and other therapies intended to restore healthy functioning2 7,m7 psychiatric or psychological conditions associated with or exacerbated by such procedures1 including depression1 anxiety1 trauma1 suicidality1 grief1 regret1 identity distress1 body-image disturbance1 or dissociation2 7,n7 diagnostic testing1 specialist evaluations1 fertility assessments1 hormone monitoring1 cancer screening1 and long-term medical surveillance necessitated by altered anatomy or prior exposure to puberty blockers1 cross-sex hormones1 or sex-rejecting surgeries2 7,o7 fertility services that seek to cooperate with1 or restore the healthy physiology and anatomy of1 the human reproductive system1 without the use of methods that circumvent natural human functions1 such as any treatments or procedures that involve the handling of a human egg or embryo outside the body2 7,p7 breast cancer in men on estrogen and certain cancers in women on testosterone2 and 7,q7 any other physical1 psychological1 reproductive1 endocrine1 neurologic1 cardiovascular1 musculoskeletal1 or metabolic injury1 impairment1 complication1 or condition resulting from or associated with a sex-rejecting procedure4 7#e7 ,sex ,the term sex1 when referring to an individual's sex1 means to refer to either male or female1 as genetically determined at fertilization4 7#f7 ,sex-rejecting procedure 7,a7 ,in general ,the term sex-rejecting procedure means any medical or surgical intervention for the purpose of attempting to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex1 including-- 7i7 gonadotropin-releasing hormone 7,gn,r,h7 agonists or any other puberty-blocking or suppressing drugs to stop or delay normal puberty2 7ii7 testosterone1 dihydrotestosterone 7,,dht71 or other androgens1 estrogen1 progesterone1 to an individual at doses that are supraphysiologic to what would normally be produced endogenously in a healthy individual of the same age and sex1 as well as anti-androgen medications2 7iii7 castration2 7iv7 orchiectomy2 7v7 scrotoplasty2 7vi7 implantation of erection or testicular prostheses2 7vii7 vasectomy2 7viii7 hysterectomy2 7ix7 oophorectomy2 7x7 ovariectomy2 7xi7 reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty2 7xii7 metoidioplasty2 7xiii7 penectomy2 7xiv7 phalloplasty2 7xv7 vaginoplasty2 7xvi7 clitoroplasty2 7xvii7 vaginectomy2 7xviii7 vulvoplasty2 7xix7 reduction thyrochondroplasty2 7xx7 chondrolaryngoplasty2 7xxi7 mastectomy2 7xxii7 tubal ligation2 7xxiii7 sterilization2 7xxiv7 any plastic1 cosmetic1 or aesthetic surgery that feminizes or masculinizes the facial or other physiological features of an individual2 7xxv7 any placement of chest implants to create feminine breasts2 7xxvi7 any placement of fat or artificial implants in the gluteal region2 7xxvii7 augmentation mammoplasty2 7xxviii7 liposuction2 7xxix7 lipofilling2 7xxx7 voice surgery2 7xxxi7 hair reconstruction2 7xxxii7 pectoral implants2 and 7xxxiii7 the removal of any otherwise healthy or non-diseased body part or tissue4 7,b7 ,exceptions ,the term sex-rejecting procedure does not include the following when furnished by a health care professional with the consent of such individual or1 if applicable1 such individual's parents or legal guardian3 7i7 ,services to individuals born with a medically verifiable disorder of sex development1 including an individual with external sex characteristics that are irresolvably ambiguous1 such as an individual born with #df1,,xx chromosomes with virilization1 an individual born with #df1,,xy chromosomes with undervirilization1 or an individual born having both ovarian and testicular tissue4 7ii7 ,services provided when a physician has otherwise diagnosed a disorder of sex development in which the physician has determined through genetic or biochemical testing that the individual does not have healthy sex chromosome structure1 sex steroid hormone production1 or sex steroid hormone action for a healthy individual of the same sex and age4 7iii7 ,the treatment of any infection1 injury1 disease1 or disorder that has been caused by or exacerbated by the performance of sex-rejecting procedures1 whether or not the sex-rejecting procedure was performed in accordance with ,state and ,federal law and whether or not funding for the procedure is permissible under this section4 7iv7 ,any procedure undertaken because the individual suffers from a physical disorder1 physical injury1 or physical illness 7but not claimed mental distress7 that would1 as certified by a physician1 place the individual in imminent danger of death or impairment of major bodily function1 unless the procedure is performed4 7v7 ,puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty4 7vi7 ,male circumcision4 4 7b7 ,,erisa 7#a7 ,in general ,subpart ,b of part #g of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe et seq47 is amended by adding at the end the following new section3 #gbg4 ,required coverage of items and services to address the harms of sex-rejecting procedures 7a7 ,in general ,a group health plan and a health insurance issuer offering group health insurance coverage shall1 in the case such plan or coverage provides benefits with respect to any sex-rejecting procedure1 also provide benefits for items and services furnished to an individual who has received any such procedure to address the harms of such procedure 7including restorative care71 regardless of whether-- 7#a7 such individual received benefits with respect to the sex-rejecting procedure under the individual's plan or coverage2 or 7#b7 such plan or issuer provides benefits under the individual's plan or coverage for the sex-rejecting procedure4 7b7 ,application of financial requirements and treatment limitations ,a group health plan and a health insurance issuer offering group health insurance coverage shall ensure that1 with respect to items and services for which benefits to address the harms of sex-rejecting procedures are required to be provided under such plan or coverage under subsection 7a7-- 7#a7 the financial requirements applicable to such items and services are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan or coverage and there are no separate cost-sharing requirements that are applicable only with respect to such items and services2 and 7#b7 the treatment limitations applicable to such items and services are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan or coverage and there are no separate treatment limitations that are applicable only with respect to such items and services4 7c7 ,definitions ,in this section3 7#a7 ,female ,referring to a natural person1 the term female means an individual characterized by a reproductive system naturally organized to produce 7at maturity1 absent disruption or congenital anomaly7 large gametes 7ova74 7#b7 ,financial requirement2 predominant2 treatment limitation ,the terms financial requirement1 predominant1 and treatment limitation have the meaning given such terms in clauses 7i7 through 7iii71 respectively1 of section #gab7;a77#c77;,b71 except that the term financial requirement shall include aggregate lifetime limits and annual limits4 7#c7 ,male ,referring to a natural person1 the term male means an individual characterized by a reproductive system naturally organized to produce 7at maturity1 absent disruption or congenital anomaly7 small gametes 7sperm74 7#d7 ,restorative care ,the term restorative care means items and services furnished to an individual who has received any sex-rejecting procedure at any point during the individual's lifetime to address1 mitigate1 monitor1 treat1 or reverse the harms1 complications1 and adverse effects of such procedure1 including interventions intended to restore1 to the greatest extent practicable1 healthy human form and functioning4 ,such care includes items and services furnished to address-- 7,a7 impaired reproductive capacity1 diminished ovarian reserve1 impaired spermatogenesis1 or other reproductive-system injury2 7,b7 endocrine dysfunction1 hormonal imbalance1 hypogonadism1 dependence on exogenous hormones1 or other disruption of healthy endocrine function2 7,c7 impaired sexual function1 including loss of sexual sensation1 anorgasmia1 erectile dysfunction1 genital pain1 vaginal stenosis1 diminished libido1 or other sexual dysfunction2 7,d7 urinary dysfunction1 including urinary incontinence1 urinary retention1 urethral complications1 recurrent urinary tract infections1 or other genitourinary injury2 7,e7 resultant vocal cord damage1 permanent voice changes1 vocal dysfunction1 or impaired speech2 7,f7 female hirsutism1 male-pattern baldness1 breast atrophy1 breast development1 or other secondary-sex-characteristic changes caused by cross-sex hormones2 7,g7 osteoporosis1 osteopenia1 impaired bone development1 fractures1 reduced bone density1 or other skeletal disorders associated with puberty suppression or cross-sex hormone use2 7,h7 cardiovascular disease1 thromboembolic disease1 hypertension1 stroke1 myocardial infarction1 metabolic syndrome1 diabetes1 or other cardiovascular or metabolic complications associated with such procedures2 7,i7 surgical complications1 including infection1 fistula formation1 stenosis1 tissue necrosis1 chronic pain1 nerve damage1 graft failure1 implant complications1 wound complications1 or the need for revision surgery2 7,j7 loss1 removal1 alteration1 or impairment of healthy reproductive organs1 breasts1 genital structures1 or other healthy tissues2 7,k7 reconstructive1 regenerative1 prosthetic1 plastic1 or other surgical interventions intended to restore healthy anatomy1 appearance1 or physiological function2 7,l7 rehabilitation services1 including speech therapy1 physical therapy1 occupational therapy1 pelvic floor therapy1 sexual health counseling1 and other therapies intended to restore healthy functioning2 7,m7 psychiatric or psychological conditions associated with or exacerbated by such procedures1 including depression1 anxiety1 trauma1 suicidality1 grief1 regret1 identity distress1 body-image disturbance1 or dissociation2 7,n7 diagnostic testing1 specialist evaluations1 fertility assessments1 hormone monitoring1 cancer screening1 and long-term medical surveillance necessitated by altered anatomy or prior exposure to puberty blockers1 cross-sex hormones1 or sex-rejecting surgeries2 7,o7 fertility services that seek to cooperate with1 or restore the healthy physiology and anatomy of1 the human reproductive system1 without the use of methods that circumvent natural human functions1 such as any treatments or procedures that involve the handling of a human egg or embryo outside the body2 7,p7 breast cancer in men on estrogen and certain cancers in women on testosterone2 and 7,q7 any other physical1 psychological1 reproductive1 endocrine1 neurologic1 cardiovascular1 musculoskeletal1 or metabolic injury1 impairment1 complication1 or condition resulting from or associated with a sex-rejecting procedure4 7#e7 ,sex ,the term sex1 when referring to an individual's sex1 means to refer to either male or female1 as genetically determined at fertilization4 7#f7 ,sex-rejecting procedure 7,a7 ,in general ,the term sex-rejecting procedure means any medical or surgical intervention for the purpose of attempting to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex1 including-- 7i7 gonadotropin-releasing hormone 7,gn,r,h7 agonists or any other puberty-blocking or suppressing drugs to stop or delay normal puberty2 7ii7 testosterone1 dihydrotestosterone 7,,dht71 or other androgens1 estrogen1 progesterone1 to an individual at doses that are supraphysiologic to what would be produced endogenously in a healthy individual of the same age and sex1 as well as anti-androgen medications2 7iii7 castration2 7iv7 orchiectomy2 7v7 scrotoplasty2 7vi7 implantation of erection or testicular prostheses2 7vii7 vasectomy2 7viii7 hysterectomy2 7ix7 oophorectomy2 7x7 ovariectomy2 7xi7 reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty2 7xii7 metoidioplasty2 7xiii7 penectomy2 7xiv7 phalloplasty2 7xv7 vaginoplasty2 7xvi7 clitoroplasty2 7xvii7 vaginectomy2 7xviii7 vulvoplasty2 7xix7 reduction thyrochondroplasty2 7xx7 chondrolaryngoplasty2 7xxi7 mastectomy2 7xxii7 tubal ligation2 7xxiii7 sterilization2 7xxiv7 any plastic1 cosmetic1 or aesthetic surgery that feminizes or masculinizes the facial or other physiological features of an individual2 7xxv7 any placement of chest implants to create feminine breasts2 7xxvi7 any placement of fat or artificial implants in the gluteal region2 7xxvii7 augmentation mammoplasty2 7xxviii7 liposuction2 7xxix7 lipofilling2 7xxx7 voice surgery2 7xxxi7 hair reconstruction2 7xxxii7 pectoral implants2 and 7xxxiii7 the removal of any otherwise healthy or non-diseased body part or tissue4 7,b7 ,exceptions ,the term sex-rejecting procedure does not include the following when furnished by a health care professional with the consent of such individual or1 if applicable1 such individual's parents or legal guardian3 7i7 ,services to individuals born with a medically verifiable disorder of sex development1 including an individual with external sex characteristics that are irresolvably ambiguous1 such as an individual born with #df1,,xx chromosomes with virilization1 an individual born with #df1,,xy chromosomes with undervirilization1 or an individual born having both ovarian and testicular tissue4 7ii7 ,services provided when a physician has otherwise diagnosed a disorder of sex development in which the physician has determined through genetic or biochemical testing that the individual does not have healthy sex chromosome structure1 sex steroid hormone production1 or sex steroid hormone action for a healthy individual of the same sex and age4 7iii7 ,the treatment of any infection1 injury1 disease1 or disorder that has been caused by or exacerbated by the performance of sex-rejecting procedures1 whether or not the sex-rejecting procedure was performed in accordance with ,state and ,federal law and whether or not funding for the procedure is permissible under this section4 7iv7 ,any procedure undertaken because the individual suffers from a physical disorder1 physical injury1 or physical illness 7but not claimed mental distress7 that would1 as certified by a physician1 place the individual in imminent danger of death or impairment of major bodily function1 unless the procedure is performed4 7v7 ,puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty4 7vi7 ,male circumcision4 4 7#b7 ,clerical amendment ,the table of contents in section #a of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #ajja note7 is amended by inserting after the item relating to section #gbf the following new item3 ,sec4 #gbg4 ,required coverage of items and services to address the harms of sex-rejecting procedures4 4 7c7 ,,irc 7#a7 ,in general ,subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new section3 #ihbg4 ,required coverage of items and services to address the harms of sex-rejecting procedures 7a7 ,in general ,a group health plan shall1 in the case such plan provides benefits with respect to any sex-rejecting procedure1 also provide benefits for items and services furnished to an individual who has received any such procedure to address the harms of such procedure 7including restorative care71 regardless of whether-- 7#a7 such individual received benefits with respect to the sex-rejecting procedure under the individual's plan2 or 7#b7 such plan provides benefits under the individual's plan for the sex-rejecting procedure4 7b7 ,application of financial requirements and treatment limitations ,a group health plan shall ensure that1 with respect to items and services for which benefits to address the harms of sex-rejecting procedures are required to be provided under such plan under subsection 7a7-- 7#a7 the financial requirements applicable to such items and services are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan and there are no separate cost-sharing requirements that are applicable only with respect to such items and services2 and 7#b7 the treatment limitations applicable to such items and services are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan and there are no separate treatment limitations that are applicable only with respect to such items and services4 7c7 ,definitions ,in this section3 7#a7 ,female ,referring to a natural person1 the term female means an individual characterized by a reproductive system naturally organized to produce 7at maturity1 absent disruption or congenital anomaly7 large gametes 7ova74 7#b7 ,financial requirement2 predominant2 treatment limitation ,the terms financial requirement1 predominant1 and treatment limitation have the meaning given such terms in clauses 7i7 through 7iii71 respectively1 of section #ihab7;a77#c77;,b71 except that the term financial requirement shall include aggregate lifetime limits and annual limits4 7#c7 ,male ,referring to a natural person1 the term male means an individual characterized by a reproductive system naturally organized to produce 7at maturity1 absent disruption or congenital anomaly7 small gametes 7sperm74 7#d7 ,restorative care ,the term restorative care means items and services furnished to an individual who has received any sex-rejecting procedure at any point during the individual's lifetime to address1 mitigate1 monitor1 treat1 or reverse the harms1 complications1 and adverse effects of such procedure1 including interventions intended to restore1 to the greatest extent practicable1 healthy human form and functioning4 ,such care includes items and services furnished to address-- 7,a7 impaired reproductive capacity1 diminished ovarian reserve1 impaired spermatogenesis1 or other reproductive-system injury2 7,b7 endocrine dysfunction1 hormonal imbalance1 hypogonadism1 dependence on exogenous hormones1 or other disruption of healthy endocrine function2 7,c7 impaired sexual function1 including loss of sexual sensation1 anorgasmia1 erectile dysfunction1 genital pain1 vaginal stenosis1 diminished libido1 or other sexual dysfunction2 7,d7 urinary dysfunction1 including urinary incontinence1 urinary retention1 urethral complications1 recurrent urinary tract infections1 or other genitourinary injury2 7,e7 resultant vocal cord damage1 permanent voice changes1 vocal dysfunction1 or impaired speech2 7,f7 female hirsutism1 male-pattern baldness1 breast atrophy1 breast development1 or other secondary-sex-characteristic changes caused by cross-sex hormones2 7,g7 osteoporosis1 osteopenia1 impaired bone development1 fractures1 reduced bone density1 or other skeletal disorders associated with puberty suppression or cross-sex hormone use2 7,h7 cardiovascular disease1 thromboembolic disease1 hypertension1 stroke1 myocardial infarction1 metabolic syndrome1 diabetes1 or other cardiovascular or metabolic complications associated with such procedures2 7,i7 surgical complications1 including infection1 fistula formation1 stenosis1 tissue necrosis1 chronic pain1 nerve damage1 graft failure1 implant complications1 wound complications1 or the need for revision surgery2 7,j7 loss1 removal1 alteration1 or impairment of healthy reproductive organs1 breasts1 genital structures1 or other healthy tissues2 7,k7 reconstructive1 regenerative1 prosthetic1 plastic1 or other surgical interventions intended to restore healthy anatomy1 appearance1 or physiological function2 7,l7 rehabilitation services1 including speech therapy1 physical therapy1 occupational therapy1 pelvic floor therapy1 sexual health counseling1 and other therapies intended to restore healthy functioning2 7,m7 psychiatric or psychological conditions associated with or exacerbated by such procedures1 including depression1 anxiety1 trauma1 suicidality1 grief1 regret1 identity distress1 body-image disturbance1 or dissociation2 7,n7 diagnostic testing1 specialist evaluations1 fertility assessments1 hormone monitoring1 cancer screening1 and long-term medical surveillance necessitated by altered anatomy or prior exposure to puberty blockers1 cross-sex hormones1 or sex-rejecting surgeries2 7,o7 fertility services that seek to cooperate with1 or restore the healthy physiology and anatomy of1 the human reproductive system1 without the use of methods that circumvent natural human functions1 such as any treatments or procedures that involve the handling of a human egg or embryo outside the body2 7,p7 breast cancer in men on estrogen and certain cancers in women on testosterone2 and 7,q7 any other physical1 psychological1 reproductive1 endocrine1 neurologic1 cardiovascular1 musculoskeletal1 or metabolic injury1 impairment1 complication1 or condition resulting from or associated with a sex-rejecting procedure4 7#e7 ,sex ,the term sex1 when referring to an individual's sex1 means to refer to either male or female1 as genetically determined at fertilization4 7#f7 ,sex-rejecting procedure 7,a7 ,in general ,the term sex-rejecting procedure means any medical or surgical intervention for the purpose of attempting to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex1 including-- 7i7 gonadotropin-releasing hormone 7,gn,r,h7 agonists or any other puberty-blocking or suppressing drugs to stop or delay normal puberty2 7ii7 testosterone1 dihydrotestosterone 7,,dht71 or other androgens1 estrogen1 progesterone1 to an individual at doses that are supraphysiologic to what would normally be produced endogenously in a healthy individual of the same age and sex1 as well as anti-androgen medications2 7iii7 castration2 7iv7 orchiectomy2 7v7 scrotoplasty2 7vi7 implantation of erection or testicular prostheses2 7vii7 vasectomy2 7viii7 hysterectomy2 7ix7 oophorectomy2 7x7 ovariectomy2 7xi7 reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty2 7xii7 metoidioplasty2 7xiii7 penectomy2 7xiv7 phalloplasty2 7xv7 vaginoplasty2 7xvi7 clitoroplasty2 7xvii7 vaginectomy2 7xviii7 vulvoplasty2 7xix7 reduction thyrochondroplasty2 7xx7 chondrolaryngoplasty2 7xxi7 mastectomy2 7xxii7 tubal ligation2 7xxiii7 sterilization2 7xxiv7 any plastic1 cosmetic1 or aesthetic surgery that feminizes or masculinizes the facial or other physiological features of an individual2 7xxv7 any placement of chest implants to create feminine breasts2 7xxvi7 any placement of fat or artificial implants in the gluteal region2 7xxvii7 augmentation mammoplasty2 7xxviii7 liposuction2 7xxix7 lipofilling2 7xxx7 voice surgery2 7xxxi7 hair reconstruction2 7xxxii7 pectoral implants2 and 7xxxiii7 the removal of any otherwise healthy or non-diseased body part or tissue4 7,b7 ,exceptions ,the term sex-rejecting procedure does not include the following when furnished by a health care professional with the consent of such individual or1 if applicable1 such individual's parents or legal guardian3 7i7 ,services to individuals born with a medically verifiable disorder of sex development1 including an individual with external sex characteristics that are irresolvably ambiguous1 such as an individual born with #df1,,xx chromosomes with virilization1 an individual born with #df1,,xy chromosomes with undervirilization1 or an individual born having both ovarian and testicular tissue4 7ii7 ,services provided when a physician has otherwise diagnosed a disorder of sex development in which the physician has determined through genetic or biochemical testing that the individual does not have healthy sex chromosome structure1 sex steroid hormone production1 or sex steroid hormone action for a healthy individual of the same sex and age4 7iii7 ,the treatment of any infection1 injury1 disease1 or disorder that has been caused by or exacerbated by the performance of sex-rejecting procedures1 whether or not the sex-rejecting procedure was performed in accordance with ,state and ,federal law and whether or not funding for the procedure is permissible under this section4 7iv7 ,any procedure undertaken because the individual suffers from a physical disorder1 physical injury1 or physical illness 7but not claimed mental distress7 that would1 as certified by a physician1 place the individual in imminent danger of death or impairment of major bodily function1 unless the procedure is performed4 7v7 ,puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for a minor experiencing precocious puberty4 7vi7 ,male circumcision4 4 7#b7 ,clerical amendment ,the table of sections for subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new item3 ,sec4 #ihbg4 ,required coverage of items and services to address the harms of sex-rejecting procedures4 4 7d7 ,effective date ,the amendments made by this section shall apply with respect to plan years beginning on or after ,january #a1 #bjbg4